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April 19, 2004

Coding for Cervical Cancer
Vol. 16 No. 8 p. 34

Cervical cancer, which is uncontrolled growth of severely abnormal cells of the cervix, is the second most common cancer in women worldwide, second only to breast cancer. The human papillomavirus (HPV), a sexually transmitted infection, is responsible for the majority of cervical cancer cases because it causes the cervical cells to change. If the immune system cannot fight off HPV, the virus eventually converts some cells on the surface of the cervix into cancer cells.

The development of cervical cancer is gradual and begins as a precancerous condition called dysplasia or cervical intraepithelial neoplasia (CIN). CIN is a term used to describe abnormal changes and is classified according to the degree of cell abnormality. Dysplasia may clear up on its own without treatment. However, if the abnormal cell changes persist over time and become severe, these cells can develop into cancer cells. Cervical dysplasia is classified to ICD-9-CM code 622.1. Other terms that are classified to code 622.1 include CIN I, CIN II, high-grade squamous intraepithelial dysplasia, and low-grade squamous intraepithelial dysplasia.

CIN III and carcinoma in situ of the cervix are classified to code 233.1. If CIN is documented but not specified as to type, assign code 622.1. Primary malignancy of the cervix is classified to category code 180. The fourth-digit subcategory depends on the specified location.

If the cervical dysplasia or carcinoma of the cervix is caused by HPV, then assign code 079.4 as a secondary diagnosis.

Risk Factors
Certain factors may increase a woman’s risk for developing cervical dysplasia or cancer, such as having many sexual partners, which increases risk for HPV infection; early sexual activity (before the age of 17); other sexually transmitted diseases; cigarette smoking; impaired immune system; use of birth control pills for more than five years; and women whose mothers took the hormone diethylstilbestrol during pregnancy to prevent miscarriage.

Signs and Symptoms
Early cervical cancer exhibits no symptoms. The first sign is an abnormal Papanicolaou (Pap) smear test result. As the disease progresses, the following signs and symptoms may appear: bleeding from vagina when something comes in contact with the cervix; watery, bloody discharge from the vagina that may be heavy and have a foul odor; pain during sexual intercourse; low back pain; and dysuria.

Screening and Diagnosis
A Pap smear test is the most successful and accurate method of early detection of cervical dysplasia or cervical cancer. If the Pap test indicates abnormal cell changes, further tests will be done to confirm or rule out the diagnosis of cervical cancer. Diagnostic tests may include colposcopy, cervical biopsy, endocervical curettage, and cone biopsy.

Some of these diagnostic tests are also performed to treat cervical cancer. Therefore, the diagnosis may be confirmed and treated at the same time. Documentation of an abnormal cervical Pap smear test without documentation of a specific diagnosis is assigned to code 795.0x. The fifth-digit subclassification classifies the specific type of abnormal cell change identified by the Pap smear.

The HC2 High-Risk HPV DNA test can identify 13 of the high-risk strains of HPV that can cause abnormal changes in the cells of the cervix. HPV can live for years and may not show up on a Pap test until years after it has been contracted.

Staging
After confirming the diagnosis of cervical cancer, the physician may perform other diagnostic tests to determine the stage, such as blood tests, chemistry screen, bone scan, x-rays, colonoscopy, cystoscopy, proctoscopy, hysteroscopy, and intravenous pyelography.

The stage will determine the treatment plan for the patient. The following are the major stage categories:
• Stage I — cancer is confined to the cervix area
• Stage II — nearby lymph node involvement
• Stage III — nearby lymph node involvement and pelvic organ involvement
• Stage IV — extensive lymph node involvement or cancer has spread to other body organs (metastatic disease)

Treatment
The treatment plan for cervical cancer depends on the type of cancer, the stage, tumor size, age, and overall health of the patient. Preinvasive stage (such as CIN and carcinoma in situ) may be treated by one of the following methods:
• Cone biopsy (67.2) involves the surgical removal with a scalpel of a cone-shaped piece of cervical tissue where the abnormality is found.
• Cryosurgery of cervix (67.33) uses liquid nitrogen to freeze and kill cancerous and precancerous cells. Code 67.33 also includes cryoconization of cervix, which is a cone biopsy done by cryosurgery.
• Loop electrosurgical excision procedure (67.32) uses a heated wire loop to pass electrical currents, which cuts like a surgeon’s knife and removes cells from the mouth of the cervix. It may also be referred to as large loop excision of the transformation zone. Code 67.32 includes electroconization of cervix, which is a cone biopsy performed by electrical current heat.
• Laser ablation of cervix (67.39) uses a narrow beam of intense light and heat at close range to kill cancerous and precancerous cells.
• Hysterectomy (68.4 or 68.5x) is the removal of the cervix and uterus. Assign an additional code(s) for synchronous removal of fallopian tubes and ovaries (65.3x-65.6x).

Invasive cervical cancer may be treated with a simple hysterectomy (as described above) when invasion is less than 3 millimeters into the cervix. If the invasion is greater than 3 millimeters into the cervix, a radical hysterectomy (68.6 or 68.7) may be performed. A radical hysterectomy involves the removal of the cervix, uterus, and part of the vagina. Also code any synchronous lymph node dissection (40.3 or 40.5) and removal of fallopian tubes and ovaries (65.3x-65.6x).

Prevention
A new vaccine may be available to prevent cervical cancer. The vaccine works by making patients immune to the HPV type-16, the leading cause of cervical cancer. However, the vaccine does not prevent every virus that causes the disease. At this time, the vaccine is experimental and won’t be available for several years.

Coding and sequencing for cervical cancer are dependent upon the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Health Information Systems (800-367-2447), a leading supplier of coding and classification systems to nearly 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information.

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